Solved by verified expert:Please review the feedback on your paper. Correct with new revision for final grade.The Subjective and objective review were incomplete. you had multiple diagnosis but one plan.This professor is very critical. the corrected is in red.
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Running head: PEDIATRIC PNEUMONIA
Diagnostic and Clinical Reasoning for Pediatric Pneumonia
June 6, 2019
Chief complaint: The child aged three and in company of her mother presents at the facility with
flu-like symptoms of stuffy nose, cough, and fever.
History of present illness
1. Onset – the parent notes that the cough manifested about 24 hours ago while the fever
manifested the previous night.
2. Location – the disorder affects the respiratory system
3. Duration – the approximated duration of the first signs of the ailment is 24 hours
4. Characteristics – the ailment is characterized by troubled breathing, productive cough,
5. Associated factors – chest pain aggravated by deep breathing or coughing
6. Relieving factors – hydration
7. Treatment – piriton
8. Summary – the mother brought the toddler in the early morning hours for medical
evaluation. The toddler presents with a cough fever, stuffy nose, and fever indicative of a
respiratory disorder. The mother notes that the ill look manifested on the day before
worsening in the previous night. She had suspected a cold and given piriton to calm the
condition but the condition increased in severity. The disorder is characterized by
shivering, breathlessness, and productive cough. Coughing and deep breathing aggravates
the situation and hydration seems to provide a relief.
Past medical history: the toddler suffered pneumonia two months after delivery that led to a
five days hospitalization. She successfully recovered from ailment without any complication and
since then has not suffered any respiratory infection of such magnitude, except two cases of a
Allergies: the toddler has no history of allergy to any medication, food, or pets. She has been
brought up with pets ever since she was bone and has not shown any medical reaction to their
presence. The mother does not use perfumed cosmetics and notes using non-perfumed jelly and
soap on her baby.
Medications: the toddler is currently under no prescribed medication
Social history: Both parents are African American who relocated in the US few years ago. The
father, who is an engineer, is an active smoker and even though he does not smoke in the house
living area, he mainly does it in his house library where the child likes spending time whenever
he is around. Currently, the mother is a stay home mom and plans to look for a job once the child
is older enough to join nursery school.
Family history: Her maternal grandmother is asthmatic but her mother has no history of chronic
respiratory disorders. Her father suffers frequent bronchitis attacks, which doctors attribute to
smoking. Her paternal grandfather develops respiratory reactions during winters, which
developed after he became a senior citizen.
Health maintenance: the child has undertaken all immunizations required ever since she was
born. Despite her love for sweet snacks, her mother has ensured that she consumes a balanced
diet and adequate fluids on a daily basis. At least twice a week, she accompanies her mother to a
nearby park where they run and exercise their dog pet.
Review of system
1. General – ill feeling
2. Skin – normal
3. HEENT – headache, runny nose
4. Neck – normal
5. Cardiovascular – normal
6. Lungs – cough, shortness of breath
7. Gastrointestinal – loss of appetite, nausea, and vomiting
8. Genito-urinary – normal
9. Periphery vascular – normal
10. Musculoskeletal – lethargy
11. Neurological – irritability
12. Endocrine – fatigue
13. Psychological – normal
1. Vital signs: T- 101.2F, HR- 125, RR- 46, BP – 70/46, decreased oxygen saturation, Wt –
2. General appearance: distressed
3. HEENT: flaring of nostrils
4. Neck: normal lymph nodes and use of neck muscles when breathing
5. CV: normal heart sounds, no rub, no rales, normal hearth expansion
6. Lungs: increased tactile fremitus on palpation, dullness on percussion, and rhonchi,
crackle, vocal fremitus, bronchial breath sounds, and reduced breath sounds on
7. Abd: normal abdominal quadrants and use of abdominal muscles when breathing
8. GU: normal
9. PV: normal
10. MSK: normal
11. Neuro: normal
12. Psych: normal
Diagnostic tests: rapid strep test and oxygen saturation test
Diagnostics: chest x-ray, blood test, pulse oximetry, and sputum culture,
Therapeutic: gentamicin 35 mg IV q 8h for 5 days and amoxicillin 420 mg IV q 12h for 7 days
Educational Plan – good hand hygiene and disinfection of surface to protect baby from
respiratory infections and vaccination as well as avoidance of crowds during flu and cold season.
In addition, education on the link between pneumonia and cigarette smoke was provided.
Collaboration – collaborated with pediatric pulmonologist during childcare.
Clinical Decision Making
The most usual pathway for acquiring pneumonia is inhalation of aerosolized droplets of
5 micrometer because of their capacity to evade the respiratory host defenses, thereby reaching
the alveoli (Cillóniz, Cardozo, & García-Vidal, 2018). Normally, the lung can employ alveolar
macrophages to filter out substances of 0.5 to 2 micrometer. Disruption of the balance between
the systemic and local defense mechanism and the organism inhabiting the inferior respiratory
tract results in the inflammation of the lung parenchyma. The usual defense processes
encompassed in pneumonia pathogenesis involves accumulation of secretions, impaired cough
reflex, mucociliary clearance, and system protective processes like complement-mediated and
humoral immunity. The resident macrophages serve to safeguard the lung from intruding
organisms. They inundate the disease causing microorganisms and trigger signal compounds or
cytokines like IL-1, IL-8, and TNF-a that engage inflammatory cells like neutrophils to the
infection area (Jain & Bhardwaj, 2018). The macrophages also act to present the antigens to the
T lymphocytes that activate both humoral and cellular protective professes, initialize
complement processes and make antibodies against the intruders. This results in lung
parenchyma inflammation and render lining capillaries leaky leading to exudate congestion,
underlying pathogenesis of the ailment.
Gentamicin is a broad spectrum antibiotic in the class aminoglycoside, principally
utilized to treat infections caused by gram-negative pathogens. Typically, this formulation is
utilized in combination with other agents that are active against gram-positive pathogens.
Gentamicin provides antimicrobial effects against the etiological pathogen by irreversibly
binding to 16S rRNA and 30S- subunit protein. Particularly, this drug binds to four nucleotides
of a single amino acid of protein S12 and 16S rRNA. The action affects the decoding site in the
locale of nucleotide 1400 in 16S rRNA of 30S subunit. This area interrelates with the wobble
base in the anticodon of tRNA resulting in intrusion with the initiation multiplex. This misleads
the mRNA causing insertion of incorrect amino acids into the polypeptide resulting in toxic or
nonoperational peptides and the disintegration of polysomes into nonfunctional monosomes. For
efficacious treatment of pneumonia, gentamicin is combined with amoxicillin, a bactericidal
penicillin that interrupts the generation of cell wall mucopeptides during active replication.
Clinical Diagnostic Reasoning
The diagnoses examined in this scenario include pneumonia, asthma, bronchitis, and
bronchiolitis. The differentiating elements from the physical exam included intensity of breath
sounds, egophony, and ear and eye involvement. The key assessment finding that led to
pneumonia diagnosis include, lack of history of allergic reactions, the absence of otitis media,
the absence of conjunctivitis, and reduced intensity of breath sounds. Ordering for a complete
blood count was to help identify the etiological pathogen, pulse oximetry to assess the saturation
of oxygen in gore, and sputum culture to identify the cause of infection. X-ray was imperative to
diagnose pneumonia and establish the location and extent of the infection (Stephen, Sain,
Maduh, & Jeong, 2019). Worth a note, C-reactive protein and procalcitonin tests were not
relevant in this diagnosis because the radiological and clinical findings were clear (Jain &
Bhardwaj, 2018). Antibiotic prescription using gentamycin and amoxicillin, which is accordance
with WHO guidance for pneumonia treatment in under 5, was imperative to treat the infection
and prevent further complications (Malla, Perera-Salazar, McFadden, & English, 2017).
Education on hand hygiene and disinfection of surfaces was imperative in order to eliminate the
pathogen in the immediate surrounding thus reducing the exposure of the child to the microbes.
Ethical and or Cultural Concerns
The first nursing ethical code observed in this patient care includes “practicing with
respect and compassion for the distinctive attributes, worth, and inherent dignity of all persons”
(Haddad & Geiger, 2018). The idea of human dignity is among the most essential professional
value in nursing practice (Parandeh, Khaghanizade, Mohammadi, & Mokhtari-Nouri, 2016).
This entails bracing the right to dignity by acclaiming the values and demands of the toddler and
parent. By setting aside potential prejudices and biases, I was able to create a patient relationship
grounded on trust, including supporting family choices and acclaiming their decisions.
Guaranteeing that the patient received appropriate care, regardless of socioeconomic status
braced the nursing goal of enabling patient live with the highest sense of well-being.
Comprehending the patient’s moral and legal rights, and giving the parent essential information
for informed medical resolution helped maintain the patient’s right to self-determination.
Collaborating with the pediatric pulmonologist and preserving good relationship with staff
helped create a compassionate, ethical, and medical efficacious environment. Guaranteeing
cultural competent nursing care by observing sensitivity, patient position, nonverbal cues, and
ensuring culturally acceptable terminologies was imperative in the preservation of cross-cultural
communication. Adopting perspectives that boosted transcultural nursing care, including
demonstrating a caring outlook, concern, and respect increased the patient and family confidence
to care. Showing empathy gave the patient and family a sense of security, understanding that
their cultural ways were comprehended and valued. Openness showed the patient and family that
their particular ways were examined and flexibility reassured them that their care was patient
Barriers to Care
Since the mother is currently not employed, the amount that earned by the father may not
be adequate to fully sustain the family. This, combined with high cost of health care can impede
the access to care for this family, thus economic barrier to care. The rising costs prescriptions,
diagnostics, and other medical services and high deductibles can make medical expensive,
impeding affordability of the services. Complexity of the US health care system can create
confusion in areas including composite innovation and information networks, contradictory
specialist opinions, compliance regime, medical terminology, and insurance billing. Other nonfinancial barriers to care in this care would include proximity of the facility, hospital stay as well
as transportation barriers (Kamimura, Panahi, Ahmmad, Pye, & Ashby, 2018). The social
determinants addressed include exposure to cigarette smoke, because cigarette smoke is a risk
element for pneumonia (Campagna, Amaradio, Sands, & Polosa, 2016). Densely populated
neighborhood would also cause crowding, which is a predisposing element for pneumonia
outbreak. Additionally, residing in a crowded city that experiences significant air pollution
increases the risk of pneumonia. The Affordable Care Act is one healthcare policy that can
positively influence financial barrier to care (Serakos & Wolfe, 2016). This healthcare policy
improves healthcare access specifically to persons without a stable healthcare insurance,
underinsured, or uninsured.
Evidence Based Practice
Question: when treating children below the age of five years, does ethical consideration improve
the quality of care?
The rationale for this PICO question is that ethical issues in nursing largely affect care
delivery, which affects patient’s outcome. The clinical queries and terms utilized to direct the
search include ethical concerns in nursing practice as well as the implication of ethical concerns
in nursing care. The resources identified for this elucidation include “Nurses’ human dignity in
education and practice” by Parandeh, Khaghanizade, Mohammadi, and Mokhtari-Nouri (2016)
as well as “Nursing Ethical Considerations” by Haddad and Geiger (2018). Ethics are a basis for
nurse and are of high clinical significance. Every patient has to make their own resolutions based
on their values and beliefs (Haddad & Geiger, 2018). Healthcare experts have a responsibility to
boost good, minimize harm, and refrain from maltreatment towards patients. Dignified care that
acclaims the patient’s values and demands is imperative to provision of quality care. Observing
ethical concerns is a care standard that braces the concept of patient-centeredness, which is an
imperative element in proof based practice. Involvement of nurses at all stages in ethics reviews
can enhance preservation of ethical principles and make it easier for them to advocate for patient
Reflecting on the decision-making on patient history, I have realized that I omitted
information regarding the patient’s family religion. Besides culture or ethnicity, religion is an
imperative element that influences personal values, practices, and beliefs. While not all religions
may have issues with modern medicine, some may have queries to areas such as drug use and
beliefs towards healing. Not addressing the issue of religion can affect the ethical provisions of
patient dignity, values and beliefs. With the mandate given to me as an FNP in ordering and
provide, I drove the development of the plan of care for this patient, including medical
assessment, diagnostic ordering, prescribing, and advocated for a five days hospital stay to
enable close monitoring.
Campagna, D., Amaradio, M. D., Sands, M. F., & Polosa, R. (2016). Respiratory infections and
pneumonia: potential benefits of switching from smoking to vaping. Pneumonia, 8(1), 4.
Cillóniz, C., Cardozo, C., & García-Vidal, C. (2018). Epidemiology, pathophysiology, and
microbiology of communityacquired pneumonia. Annals of Research Hospitals, 2(1).
Haddad, L. M., & Geiger, R. A. (2018). Nursing Ethical Considerations. In StatPearls [Internet].
Jain, V., & Bhardwaj, A. (2018). Pneumonia, Pathology. In StatPearls [Internet]. StatPearls
Kamimura, A., Panahi, S., Ahmmad, Z., Pye, M., & Ashby, J. (2018). Transportation and other
nonfinancial barriers among uninsured primary care patients. Health services research
and managerial epidemiology, 5, 2333392817749681.
Malla, L., Perera-Salazar, R., McFadden, E., & English, M. (2017). Comparative effectiveness of
injectable penicillin versus a combination of penicillin and gentamicin in children with
pneumonia characterised by indrawing in Kenya: a retrospective observational
study. BMJ open, 7(11), e019478.
Parandeh, A., Khaghanizade, M., Mohammadi, E., & Mokhtari-Nouri, J. (2016). Nurses’ human
dignity in education and practice: An integrated literature review. Iranian journal of
nursing and midwifery research, 21(1), 1.
Serakos, M., & Wolfe, B. (2016, December). The ACA: Impacts on Health, Access, and
Employment. In Forum for Health Economics and Policy (Vol. 19, No. 2, pp. 201-259).
Stephen, O., Sain, M., Maduh, U. J., & Jeong, D. U. (2019). An Efficient Deep Learning
Approach to Pneumonia Classification in Healthcare. Journal of Healthcare
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